Infant Safe Sleep
Patti Kelly, LMSW, MPHInfant Safe Sleep Program Consultant
Michigan Department of Health and Human ServicesMay, 2017
Session Objectives
Present scope of problem
Review updated American Academy of Pediatrics guidelines for infant sleep safety
Application to home visiting
What is a sleep-related infant death ?
The death of an otherwise healthy infant with no obvious trauma or disease process present, birth to one year of age, wherein the sleep environment was likely to have contributed to the death, including those ruled SIDS, SUID, suffocation, and other causes
How many babies are dying?
Every 2-3 days in Michigan a baby dies because of an
unsafe sleep environment.
From 2010-2015, 871 infants died in unsafe sleep
environments.Data from the CDC SUID Case Registry, Michigan Public Health Institute, 2017
Sleep related infant deaths
The leading cause of death in Michigan for infants aged 28 days – 12 months old
140147
131142
152159
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20
40
60
80
100
120
140
160
180
2010 2011 2012 2013 2014 2015
Sleep Related Infant Deaths in Michigan, 2010-2015
5
Data from the CDC SUID Case Registry, Michigan Public Health Institute, 2017
Unacceptable racial disparity Black infants die at over 3x the rate for white infants
American Indian infants die at over 2x the rate for white infants
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1.5
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Race of infant
Rate of infant deaths (per 1,000 live births) from sleep-related causes, 2010-2015
White Black American Indian only Other*
*Other includes Asian, Pacific Islander and Multi-racial Data from the CDC SUID Case Registry, Michigan Public Health Institute, 2017
Updated American Academy of Pediatrics (AAP) Guidelines
On October 24, 2016, AAP released their new Policy Statement: SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment
AAP Policy Statement & AAP Technical Report
AAP Guidelines
AAP Task Force on Sudden Infant Death Syndrome – representation from Pediatrics, Neonatalogy, Perinatalogy, Family Medicine & Breastfeeding
Reviewed all related publications, studies, articles, etc. 400+
Hired an outside Epidemiologist to review data
Recommendations (for infants birth to 12 months) were developed to reduce the risk of SIDS and sleep-related suffocation, asphyxia, and entrapment among infants in the general population
AAP Guidelines
Back to sleep for every sleep every caregiver
Preterm infants should be placed on the back as soon as possible – acclimate to back sleeping, along with providing parent education, prior to discharge
No evidence that placing infants on their side during the first few hours after delivery promotes clearance of amniotic fluid nor that it decreases risk of choking
Infants should be placed on the back as soon as they are ready to be placed in the bassinet
Multiples should not be co-bedded
AAP Guidelines What about babies with GER, GERD (or reflux)?
GER=gastroesophageal reflux=spit up=normal
GERD=gastroesophageal reflux disease-baby is having symptoms such as poor weight gain, etc.; a medical diagnosis; very rare in babies < 1 year old
AAP, in concurrence with the North American Society for Pediatric Gastroenterology and Nutrition: “the risk of SIDS outweighs the benefit of prone or lateral sleep position on GER; therefore, in most infants from birth to 12 months of age, supine position during sleep is recommended.”
Elevating the head of the crib (because of reflux, congestion or anything else) is not recommended
What can help parents reduce baby spitting up?
Hold baby upright after feedingsLimiting activity after feedingsBurp frequently during and after feedingsMore frequent, smaller feedingsReduce baby’s exposure to smoke in the home
AAP Guidelines
Skin to skin care is recommended for all mothers and newborns immediately following birth (as soon as the mother is medically stable, awake, and able to respond to her newborn)
Important to monitor safety both in positioning of newborn and mother’s sleepiness AAP Clinical Report
If mother wants to sleep, is sleepy or falls asleep, infant should be placed on the back in bassinet or with another support person who is awake and alert
AAP Guidelines
Infant should be placed on a firm sleep surface covered by a fitted sheet with no other bedding
Firm = maintains its shape and will not indent or conform to the shape of the infant’s head when the infant is placed on the surface
AAP recommends a crib, bassinet, portable crib, or play yard that conforms to CPSC safety standards
What about the baby box? “Currently the AAP Task Force on SIDS does not believe that there is yet
enough evidence to say anything about the potential benefit or dangers of using wahakuras, pepi-pods, or baby boxes.” Rachel Y. Moon, MD, FAAP, Chairperson AAP Task Force on SIDS, January 30, 2017
Centers for Disease Control and Prevention (CDC), MDHHS Title V Local Maternal and Child Health and MDHHS Infant Safe Sleep Program currently do not allow funds to be used for the purchase of baby boxes
Currently, baby boxes do not meet U.S. ASTM (American Society for Testing & Materials) bassinet safety standards nor U.S. CPSC (Consumer Product Safety Commission) mandatory safety standards
Boxes do not meet the CPSC’s definition of a bassinet, crib or handheld carrier –there is currently a task force looking at this; not “safety approved”
Concerns include: (for more see www.cribsforkids.org)
Babies outgrowing the box between 2-4 months of age – a high risk time
Environmental concerns – degradation due to moisture, heat, etc.
Instability if set on table, etc., danger if set on floor due to pets, etc., flammability?
All other safe sleep guidelines must be followed
Learn more
https://www.nichd.nih.gov/sts/about/Pages/faq.aspx
AAP Guidelines Car seats and other sitting devices (i.e. swings,
bouncy seats, etc.) are not recommended for routine sleep
Do not put pillows, blankets, or anything under baby, including mattress toppers, while sleeping
If cloth carriers and slings are used, ensure that infant’s head is above the fabric, face is visible and nose and mouth are clear of obstructions
https://www.cpsc.gov/content/cpsc-approves-new-federal-safety-standard-for-infant-sling-carriers
AAP Guidelines
Breastfeeding is recommended –associated with reduced risk of SIDS
The protective effect of breastfeeding increases with exclusivity
Any breastfeeding is better than no breastfeeding
Safe sleep and breastfeeding are notmutually exclusive – both can be achieved
AAP Guidelines Infant should sleep in the parents’ room, close
to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months
“the safest place for an infant to sleep is on a separate sleep surface designed for infants close to the parents’ bed”
Infants who are brought into the bed for feeding or comforting should be returned to their own crib or bassinet when the parent is ready to return to sleep
Couches or armchairs are extremely dangerous for sleeping infants
AAP acknowledges that parents frequently fall asleep while feeding the infant –
“it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep”
AAP Guidelines Based on the data, cannot conclude that bed sharing is
safe or that it can be done safely – there is always risk
If baby will be brought into bed for feeding/comforting: No pillows, sheets, blankets or any other items in the bed
that could obstruct infant breathing and/or cause overheating
All other safe sleep recommendations followed
If parent falls asleep, infant should be placed back on a separate sleep surface asap
Because of increased risk for death, baby should not be brought into the bed if: Younger than 4 months old
Born preterm or low birth weight
Mother smoked during pregnancy or if bedsharing with a smoker
Bedsharing with someone who is impaired due to fatigue, medications or substance use
Bedsharing on a soft surface, such as a waterbed, sofa, couch or armchair or with pillows, blankets, etc.
AAP Guidelines
Keep soft objects and loose bedding out of the sleep area
This includes pillows, blankets, stuffed toys and bumper pads (of any type)
A wearable blanket (sleep sack) is preferable to blankets
Doll re-enactments
AAP Guidelines
Consider offering a pacifier at naptime and bedtime
For breastfed infants, pacifier introduction should be delayed until breastfeeding is firmly established
Pacifier should not be hung around the infant’s neck, attached to the infant’s clothing, dipped in any substance or attached to a stuffed toy or other item
AAP Guidelines
Avoid smoke exposure during pregnancy and after birth
Avoid alcohol and illicit drug use during pregnancy and after birth
Pregnant women should obtain regular prenatal care
Infant should be immunized in accordance with AAP and CDC recommendations
Avoid overheating and head covering in infants
Infants should be dressed appropriately for the environment with no greater than 1 layer more than an adult would wear
Over bundling and covering of the face and head should be avoided – i.e. hats, hoods, headbands, etc.
AAP Guidelines
Avoid use of commercial devices that are inconsistent with safe sleep recommendations
Be wary of devices that claim to reduce the risk of SIDS, i.e. wedges, positioners, certain mattresses, etc.
Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS
AAP Guidelines Supervised, awake tummy time is
recommended
Supervised is key
As soon as baby falls asleep or shows signs that they are unable to keep their head up, tummy time should be discontinued
Although it may be an effective strategy to calm the infant, swaddling does not reduce the risk of SIDS
If swaddle, infant should be placed on the back & follow all safe sleep recommendations
Use of a commercially available swaddle sack or thin blanket
Swaddle snug to chest, but “hip healthy”
When an infant “exhibits signs of attempting to roll,” swaddling should be discontinued
Tips for working with families Open the conversation in a gentle, non-judgmental
manner– can’t assume family already knows (even if they have other children) or that written materials were read
Explain the why
Use visuals/demonstrations
Include all family members & visitors in the teaching
Parents cite fear of baby choking, baby discomfort and flattened skull as reasons to sleep baby on the back -address each concern, can ask: “Do you have any concerns about your baby sleeping on his back?” If they say no, then you could say “Some people are worried that their baby will choke while sleeping on the back, does that ever worry you?”
Encourage questions
Be positive, supportive and non-judgmental
Visuals
When baby is on her back, airway is on top of the esophagus (the tube that carries food). If she spits up while on her back, the food and fluid run back into the stomach and not to the lungs. When on her stomach, the esophagus is on top of the airway and food and fluid can more easily enter the airway and cause choking.
Many of the common challenges caregivers experience involve…
CRYING
Babies are hardwired to cry–oneof the ways they communicate
Teach parents about crying (i.e. how much is normal, etc.)
Can use Period of Purple Crying to help explain some of the characteristics of crying
Current opportunity to receive free Period of Purple Crying resources for families (contact Laura Rowen at [email protected])
Teach parents other ways that babies communicate so that crying spells can be reduced or avoided
Smacking lips, hands to mouth, rooting, etc. when hungry
Rubbing eyes, yawning, jerky movements, fussiness, etc. when sleepy
Learning different cries
Teach parents about the importance of a routine and giving baby attention during awake time
May need to teach parents what a routine is (and what it is not) and how it can help ease stress for the whole family
May need to teach parents how to give baby attention, i.e. hold, talk, sing, touch, look in eyes, peek a boo, rock, etc.
Peek-a-boo?
Teach parents common reasons babies cry and how to soothe
See hand-out – model behaviors for parents
What works one day, may not work the next day
Be creative – various holds, “sshing,” etc.
Teach parents how to develop a plan to deal with crying
• Check for physical needs & signs of illness/fever first
• 2 calms + 1 cope
CalmACryingBaby.org
Be realistic with parents You will be tired – what can you do ?
Ask for help
If you sit/lay down with baby, be careful not to fall asleep – babies have died when parents lay down with them on the couch or in a recliner and then fall asleep
If you are holding baby and he falls asleep, put baby in safe sleep space
If feeling sleepy, put baby in safe sleep space
Basic motivational interviewing Clients are at different levels of readiness to change
behavior
Important to display warmth, empathy (use of “I” statements) and acceptance
Important to remain non-judgmental, non-confrontational and non-adversarial
Client decides what behavior she is ready to change
Support client in her decision
Open conversation and keep the “door” open
Provide support at every step“People don’t care what you know, until they know you care”
Caring for a baby is hard work –acknowledge this
Ask permission to share information
Always emphasize the positive – build on success
Help parents anticipate challenges
Learning skills can build confidence
Follow up at future visits
State resources MDHHS Safe Sleep website www.michigan.gov/safesleep
variety of information for parents and professionals
links to additional resources (including free educational materials) and to trainings
MDHHS Infant Health Unit Request trainings/presentations; assistance with program
development
Contact: Patti Kelly, Infant Safe Sleep Program Consultant, [email protected] or 517-335-5911
Two online trainings hosted on MPHI learning network www.learning.mihealth.org
MDHHS Clearinghouse website
http://www.healthymichigan.com
CDC SUID Case Registry Project, MPHI
http://www.keepingkidsalive.org/data-publications/child_mortality_data/fact_sheets.html
National resources American Academy of Pediatrics
www.aappolicy.org
Consumer Product Safety Commission
www.cpsc.org
Cribs for Kids
www.cribsforkids.org
Eunice Kennedy Shriver National Institute of Child Health & Human Development – Safe to Sleep Campaign/Healthy Native Babies
www.nichd.nih.gov/sts
National Action Partnership to Promote Safe Sleep
www.nappss.org